INDICATORS TO MONITOR

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					     INDICATORS TO MONITOR
IMPACT OF NUTRITION PROGRAMMES
    (Excerpt from the MICAH Guide,
  A Publication of World Vision Canada)
                                      PREFACE

The MICAH Guide, A Practical handbook for Micronutrient and Health Programmes, has
been prepared by the World Vision Canada MICronutrient And Health (MICAH) team to help
standardize the monitoring and evaluation of micronutrient programmes in various countries in
Africa. The guidelines have been developed in response tot he Canadian International
Development Agency‟s (CIDA) requirements for showing programme effectiveness, as well as in
response to the needs of both programmers and communities in the field to evaluate the
effectiveness of their activities.

The MICAH Guide is based on UNICEF‟s „Practical Handbook for Multiple-Indicator
Surveys‟ – from which several chapters have been included with modifications to make them
appropriate for micronutrient surveys. These guidelines reflect contributions not only from
UNICEF, but also from other institutions including World Health Organization (WHO), Food for
the Hungry and Centre for Disease Control (CDC). Professor Rosalind Gibson from the
University of Otago provided recommendations on monitoring and evaluating the effectiveness
of micronutrient interventions. Professor George Beaton from the University of Toronto helped
identify indicators for estimating changes in Vitamin A, iodine and iron status. Input from a
variety of other professionals including Lisa Belzak (sampling methodology), Patricia David
(mortality monitoring) and Dr. Zewdie Wolde-Gabriel (vitamin A and iodine modules) has been
combined with the hard work of the World Vision Canada MICAH team, to produce a
comprehensive first draft of the Guide.

Thanks go to Carolyn MacDonald, MICAH Nutrition Officer, who coordinated and produced this
Guide; Joan Hildebrand, MICAH Nutrition Officer, who served as technical editor; and to Susan
Bryce, MICAH Office Administrator, who edited, collated and polished the Guide. Thanks also
go to other contributing members of the MICAH team – Beth Fellows, Senior Advisor for
Programme Development and Special Initiatives, who envisioned the Guide and made it
possible; Wilma Jakus, Finance Officer; Daryl Dolny, MICAH PC Analyst; Janet-Marie Huddle,
Nutrition Officer, and Liz Stevens, who re-formatted the Guide for wider distribution.

Due to numerous requests for the MICAH Guide, it has been reformatted into two sections to
meet specific programme needs and facilitate distribution: Indicators to Monitor Impact of
Nutrition Programmes and Design and Implementation of Nutrition Surveys. The content
remains unchanged from the original Guide.

This Guide is intended for the use of programme planners/implementers and for educational
purposes. Parts of the Guide may be reproduced for these uses with acknowledgement.
     Indicators to Monitor Impact of Nutrition Programmes

       1.1      Understanding Monitoring and Indicator Terms .................................................1
                1.1.1 Process Indicators ..........................................................................................2
                1.1.2 Outcome/Impact Indicators ............................................................................3

       1.2      Core Indicators to Monitor Micah Programme Objectives ................................4
                1.2.1 Indicators to Monitor Vitamin A, Iodine & Iron Deficiency .......................10
                1.2.2 Indicators for Dietary Monitoring ................................................................10
                1.2.3 Indicators for Morbidity Monitoring ............................................................11
                1.2.4 Indicators for Monitoring Changes in the
                      Health of the Population (Goal 1) ...............................................................11

       1.3      Selecting Indicators for your Programme ...........................................................12
                1.3.1 Identify Specific Micronutrient Deficiencies ...............................................12
                1.3.2 Identify the Target Groups ..........................................................................14
                1.3.3 Select Potential Interventions to Combat the Deficiencies ..........................17
                1.3.4 Recognize Characteristics of a Good Indicator ............................................17

       1.4      Sources of Information for Indicators .................................................................19
                1.4.1 Existing Data Sources ..................................................................................19
                1.4.2 New Data .....................................................................................................19

       1.5      Levels of Monitoring Indicators ...........................................................................20
                1.5.1 Level A .........................................................................................................20
                1.5.2 Level B .........................................................................................................21
                1.5.3 Level C .........................................................................................................22



                                                 APPENDICES
Appendix A-1

Flow Charts for Vitamin A, Iodine & Iron Deficiencies................................................................24

Appendix A-2

Methodology to Determine Indicators for Vitamin A, Iodine & Iron Deficiencies .......................28

Appendix A-3

Methodology for Weighing & Measuring Children .......................................................................40
Appendix A-4

International Standards for Vitamin A, Iron & Iodine Deficiencies ..............................................56

Appendix A-5

Tables for Indicator Calculation ....................................................................................................62
Indicators to Monitor Impact
of Nutrition Programmes


       Who Should Read This?

              Programme Directors
              Technical Resource Persons
              Survey Coordinators


       Why Read This? What Will You Learn?

              To understand monitoring and indicator concepts1.1
              To recognize core indicators programme objectives1.2
              To think through key considerations prior to the selection of indicators1.3
              To use appropriate sources of information for indicators1.4
              To identify different levels of monitoring indicators1.5




1.1 Understanding Monitoring and Indicator Terms
To understand the concepts surrounding monitoring and evaluation, you need to have a firm
grasp of related terms and definitions. Keep these in mind as you continue to read through this
chapter.

An indicator is the basic tool to measure progress, using a commonly agreed-upon definition of
a specific situation.

A „core‟ indicator is one which will be measured by all participants in your programme. The
choice of indicators depends upon the type of results you intend to measure.

A result is a desirable and measurable change in state that is derived from a cause-and-effect
relationship. For example, a result we desire to see is a decreased number of women with
anaemia (desirable and measurable change) due to our MICAH programme. The different types
of indicators reflect the kind of results which are measured. The two main categories of
indicators are process indicators and outcome/impact indicators.


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1.1.1          Process Indicators
The importance of monitoring the process of interventions and the management of programmes
must not be underestimated. In all areas and at all levels of monitoring, process indicators need
to be monitored.

Process indicators are used to monitor the level of programme activity required to impact the
status of a particular micronutrient. As such, they are indicators of programme effectiveness.
Different classes of process indicators include input, activity and output indicators. These are
described below.

      Input Indicators

       Inputs are the resources required (money, time or human resources) to produce a result.

       Example: Inputs into a supplementation programme aimed at pregnant women who are
       anaemic could include:

              money for purchase of iron supplements/fortificants
              time involved in distributing supplements
              people needed to educate women regarding the importance of iron.

       Input Indicators are the tools which verify that the inputs were used. These might
       include funding, human and non-human resources, infrastructure and institutions. In our
       preceding example of monitoring iron supplement distribution for anaemic women, the
       input indicators you might monitor include:

       - the number of supplements purchased per month
       - the number of trainers hired to train the existing TBAs, CHWs regarding distribution.
       - the type and amounts of materials used in training (for education/communication).
       - number of health regions involved.

      Activity Indicators

       Activities include the coordination, technical assistance and training tasks organized and
       executed by project personnel.

       Activity indicators verify that the activity was carried out with the inputs as planned.




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       For example, if you are monitoring the activity of iron supplementation to pregnant
       women through ante-natal clinics, you would monitor:

       - the number of clinics distributing iron and folic acid
       - the number of the TBA/CHWs trained on importance of iron supplements in pregnancy.
       - the number of CHW/TBAs distributing iron supplements to lactating mothers.

      Output Indicators

       Outputs are the immediate, visible, concrete and tangible consequences of project inputs
       and activities.

       Output indicators measure changes resulting from inputs and activities, often according
       to coverage and usage. Following the same example:

       - the proportion of women receiving iron/folic acid during pregnancy

1.1.2          Outcome/Impact Indicators
Outcome and impact indicators measure changes in the target population at the population level
due to the intervention, or 'downstream developmental results'.

An outcome is the result of an output, linked to programme purposes, and short-term (1-3 years).

Outcome indicators are tools which measure changes of micronutrient status of the
communities and are the focus of this handbook. They include both clinical assessments (ex.
Night blindness or goitre), and biochemical assessments (ex. breast milk vitamin A or
haemoglobin). Outcome indicators measure changes involved at population levels as a result of
the intervention.

For example, outcome indicators of supplementation of pregnant women with iron/folic acid
would include:

- the proportion of pregnant women with increased Haemoglobin (Hb)
- the proportion of the target population with improved Knowledge, Attitude, Practice (KAP)
  score on Iron.

An impact is a broader, higher level, longer-term (5-10 years) effect or consequence linked to the
programme goal or vision.

Impact Indicators measure long term changes in a given population. For example, the broader,
longer term goal of the MICAH programme is "to improve the health of women and children".
The impact indicator to be monitored is a decrease in mortality or an improvement in growth of
children under 5 years.


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At times, there is no clear difference between outcomes and impacts, therefore it is not necessary
to distinguish between them, as long as the downstream results are being assessed.

Levels of Impact

When discussing the monitoring of indicators, it is important to note that there are different
levels at which statements about the effect of programmes can be made: adequacy, plausibility,
and probability (Habicht, Victora and Vaughan, 1995). Generally, the stronger the statement
you wish to make about the impact of an intervention, the more costly the study design and data
collection methods that must be used.

Each level answers a progressively more detailed question. For example:

  At the level of adequacy:          Are the expected changes in anaemia taking place?
  At the level of plausibility:      Does the programme seem to be having an effect on
                                     anaemia?
  At the level of probability:       Is anaemia changing due to the programme beyond a
                                     reasonable doubt?

The methods and „reasonable‟ sample size of the programme evaluate impact at the level of
plausibility to answer the question, “Does the programme seem to be having an effect on anaemia
in pregnant women?” The monitoring and evaluation does not answer the question, "Is anaemia
changing due to the programme beyond a reasonable doubt?" The amount of effort, resources
and time that would need to be put into such a study are beyond the scope of this programme,
unless it becomes a research programme.

Traditionally, CIDA and NGOs have focused monitoring and evaluation on process indicators:
inputs, activities and outputs. Now CIDA also expects evaluation of outcome/impact indicators.
The remainder of this chapter will help you to understand just how this can be accomplished.



1.2 Core Indicators to Monitor Micah Programme
    Objectives
World Vision has developed a set of core outcome and impact indicators to measure progress
toward the MICAH goals. This core set will permit cross-country comparisons. The indicators
have been chosen with reference to internationally accepted standards (recommended by World
Health Organization (WHO), UNICEF, and the Micronutrient Initiative (MI)). They have been
developed in consultation with partners and international nutrition experts (Dr. George Beaton,
University of Toronto; Dr. Rosalind Gibson, University of Otago; Dr. Sonya Rabeneck, CIDA;
and Dr. Zewdie Wolde-Gabriel, independent nutrition consultant, Ethiopia).




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What are the Core Indicators?
The core indicators corresponding to MICAH goals are briefly summarized below. The core
indicators for monitoring include:

Goal/Impact:              <5 mortality
                          morbidity
                          <5 stunting, wasting

Purpose/Outcome:          Vitamin A:    night blindness
                                         Bitot‟s spots
                                         Breast milk vitamin A
                          Iron:         haemoglobin
                          Iodine:       goitre
                                         urinary iodine

Output/Output:            coverage/utilization
                          breastfeeding
                          intestinal parasites/malaria

Core indicators as well as other possible indicators are more clearly described in Table 1.1. The
core indicators are in bold print. Other possible indicators which could also be used to measure
the MICAH goals are shown in parentheses in this table.

In some cases, the alternative indicators are to be used if the interpretation of the primary
measure (e.g. haemoglobin) is in doubt and diagnostic confirmation for the population is deemed
necessary. In this case, a relatively small subsample of the population should be studied
intensively. In other cases, the alternative indicators are monitored in order to compare the effect
of the program with other indicators collected in the country.




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Table 1.1   Micah Programme Logframe

               OBJECTIVES                       INDICATORS


 GOAL          To improve micronutrient and     IMPACT INDICATORS
               health status of mothers and      under 5 mortality rates
               children through the most cost    morbidity rates
               effective and sustainable         proportion of children under 5
               interventions.                   stunted, wasted and underweight

 PURPOSE       1. Reduce prevalence of MN       OUTCOME INDICATORS (MN status)
 1.            deficiency status through        Vit. A
               increased intake of MN (Vit.      % of children 24-71 months with:
               A, Iron, Iodine).                       - night blindness
                                                       - Bitot‟s spots
                                                 % of lactating women with breast
                                                milk vitamin A < 1.05 umol/l
                                                ( % of children > 1 yr with serum retinol
                                                       <0.7 umol/l)
                                                Iron
                                                 % of preg. women with haemoglobin          <110g/l
                                                 (% of pregnant women with transferrin
                                                receptor >7.26 mg/l)
                                                Iodine
                                                 % of children 6-12 with goitre
                                                 % of children 6-12 with urinary
                                                iodine <20ug/l
                                                ( % of neonates with TSH > 5mU/l
                                                       whole blood)




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 OUTPUT        1.1 Increase intake through       OUTPUT INDICATORS
 1.1           supplementation                   1.1 coverage:
                                                 Vit. A
                                                  % of children < 5 yrs receiving VAC
                                                 q.6 mos through EPI programmes
                                                  % of school children receiving VAC
                                                 q.6 mos
                                                  % of post partum mothers receiving
                                                 VAC within 6 wks of delivery
                                                  Iron
                                                  % of women receiving iron and folic
                                                 acid once/wk during pregnancy
                                                 Iodine
                                                  % of women 15-49 yrs receiving
                                                 iodine capsules
 ACTIVITY      VAC Supplementation               ACTIVITY INDICATORS (PROCESS)
 1.1.1         1.1.1.1 children < 5 through      Vit. A
               EPI                                No. of health facilities including VAC
               1.1.1.2 school children through   with EPI .
               schools                            No. of schools distributing capsules
               1.1.1.3 lactating mothers
               through TBA or MCH.                No. of TBAs or MCHs distributing
                                                 VAC to lactating mothers.

 1.1.2         Iron Supplementation              Iron
               1.1.2.1 to pregnant women          No. of clinics distributing iron & folic
               through ante-natal clinics        acid
               1.1.2.2 treatment of anaemic
               children & women with Fe &         No. of clinics treating anaemic children
               folic acid                        & women.

 1.1.3         Iodine Supplementation            Iodine
               1.1.3.1 distribution of iodized    No. of women receiving iodized oil
               oil capsules to women of          capsules.
               child-bearing age in severely
               deficient areas.

 OUTPUT        1.2 Increase intake through       OUTPUT INDICATORS
 1.2           fortification                     1.2 utilization:
                                                 Vit. A and/or Iron
                                                  % of households using fortified food
                                                 Iodine
                                                  % of households using iodized salt


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 ACTIVITY      1.2.1 equipping 2 mills for       ACTIVITY INDICATORS
 1.2.1         capacity to fortify flour          volume of fortified flour and DMK
               1.2.2 packaging DMK               produced
               1.2.3 Social marketing DMK         volume of DMK labelled and packaged
               1.2.4 Distribution of              number of HW trained; educational
               DMK/flour                         materials
                                                  volume of flour moved from central
                                                 production area to distribution sites

 OUTPUT        1.3 Increase intake through       OUTPUT INDICATORS
 1.3           dietary modification              1.3 utilization: Vit. A and/or Iron
                                                  % of households with adequate intake
                                                 of Vit. A and iron

 ACTIVITY      1.3.1 initiate gardens in         ACTIVITY INDICATORS
 1.3.1         primary schools                    No. of schools with gardens
               1.3.2 introduce horticulture in    No. of households with backyard
               backyard gardens                  gardens.

 OUTPUT        1.4 Increase intake through       OUTPUT INDICATORS
 1.4           knowledge of MN foods             1.4 utilization:
                                                  % increase improved KAP scores
 ACTIVITY      1.4.1 promotion of exclusive      ACTIVITY INDICATORS
 1.4.1         breast feeding for 4-6 mos.        proportion of mothers implementing
               1.4.2 promotion of quality and    exclusive breast feeding
               frequent feeding of weaning        proportion of children receiving
               foods                             quality of weaning foods
               1.4.3 promotion of continued       frequency of feeding weaning foods
               breast feeding for 24 months       average duration of breast feeding
 PURPOSE       2. Reduce prevalence of           OUTCOME INDICATORS
 2             diseases that affect MN            decrease in morbidity rates
               status.                            improve under five nutritional status
                                                  (Length for age; weight for age)

 OUTPUT        2.1 Improve water and             OUTPUT INDICATORS
 2.1           sanitation conditions              Proportion of children <5 with DD
                                                  DD case admission rate to health
                                                 facility
 ACTIVITY      2.1.1 Provide potable water       ACTIVITY INDICATORS
 2.1.1         through well construction          proportion of households with safe
                                                 water supply
                                                  No. new wells constructed or water
                                                 sources protected


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 2.1.2         2.1.2 Promote latrine             proportion of households utilizing
               construction and use             latrines
                                                 number of households with new latrines

 OUTPUT        2.2 Promote control and           % of target group with intestinal
 2.2           treatment of parasitic           parasites
               diseases                         % of target group with malaria
 ACTIVITY      2.2.1 Promote community           No. communities with malaria control
 2.2.1         based malaria control             No. households using mosquito nets
               2.2.2 Promote use of mosquito
               nets
               2.2.3 Promote treatment and
               control of hookworm thru
               shoes

 OUTPUT        2.3 Improve immunization         OUTPUT INDICATORS
 2.3                                            2.3 Coverage
                                                 % of children immunized
 ACTIVITY      2.3.1 Reinforce cold chain       ACTIVITY INDICATORS
 2.3.1         2.3.2 Improve community           No. of health centres with functioning
               education                        cold chains
               2.3.3 Management and supply       Knowledge of mothers about
               of vaccines thru training        importance of immunization
                                                 No. of health centres with adequate
                                                supply of vaccines

 PURPOSE       3. Build local capacity for
 3.            delivery system
 OUTPUT        3.1 Build administrative and
 3.1           management capacity for
               micronutrient monitoring
 OUTPUT        3.2 Strengthen MCH, FP,
 3.2           EPI and Laboratory services
               (what about agricultural
               services?)
 ACTIVITY      3.2.1 Equip central lab for      ACTIVITY INDICATORS
 3.2.1         monitoring breast milk vitamin    number of samples of vitamin A
               A,                               monitored
               3.2.1 Equip health centre labs    number of samples of Hb monitored per
               for monitoring haemoglobin       month




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 OUTPUT            3.3 Training and upgrading
 3.3               personnel

These outcome indicators were selected because they:

 describe the magnitude (prevalence) of the problem(s) at inception
 describe the severity (clinical conditions) of the problem(s) at inception
 describe the impact of interventions(monitor progress to control the problem(s)



1.2.1          Indicators to Monitor Vitamin A, Iodine & Iron
               Deficiency (Purpose 1/Output 1.1,1.2 )
You may find it easier to think of monitoring your interventions by micronutrients. In this case,
flow charts showing the various core indicators to be monitored for vitamin A, iodine and iron
deficiencies, respectively are found in Appendix A1. They include different interventions and
target populations. These charts will help you to define which core indicators will be monitored
in your programme area. The methodology to be followed when determining these indicators is
outlined in Appendix A2.



1.2.2          Indicators for Dietary Monitoring
               (Purpose 1; Output 1.3-1.4)
To monitor dietary practices, you will include breast feeding practices among core indicators
(incidence and duration of exclusive and non-exclusive breast feeding). In addition to breast
milk, information about frequency of and quality of foods infants receive will be included.

For any project involving the use of fortified foods (including iodized salt) or special foods (e.g.
complementary food intended for infants) it is important to estimate the use and distribution of
the particular food - who is using it and in what amounts. These are also included as „core‟
indicators. It is not necessary to know the other foods or total nutrient intake. For iodine, total
dietary intake will be well marked by urinary iodine.

However, since the monitoring of actual nutrient intakes is very difficult and time-consuming, it
will only be used where diet modification is the main intervention. As such, it is not considered
a core indicator. When diet modification is the major intervention (ex. Malawi), information
regarding nutrient intakes and food usage patterns is very important. For example, if the
micronutrient is iron, a modified one-day recall with two replicated estimates (e.g. 2 x 1 day
recall) will be used. The outcome measure is the estimated change in proportion of individuals
with inadequate iron intakes. To approach the latter, estimates of the distribution of usual
intakes are needed. To eliminate the impact of random measurement error or day-to-day

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variation, at least two estimates of individual intake are required. A new software programme,
called SIDE, is now available from the Department of Statistics at Iowa State University. This
software is designed to make necessary distributional adjustments. You will then be able to
conduct a simplified probability assessment and estimate the change in prevalence of inadequate
intakes. However, large samples (strictly representative of the target population) may be needed
to detect differences unless the effects are very large.

1.2.3          Indicators for Morbidity Monitoring
               (Purpose 2, Outputs 2.1 & 2.2)
The core indicator for monitoring disease prevalence affecting micronutrient status is morbidity
data. Morbidity data can be collected in various forms at varying costs. In MICAH‟s
surveillance programme, one of the simplest forms will be used - the household survey which
simply records whether anyone was „sick‟ yesterday, along with a corresponding diagnosis.
This form yields a valid point prevalence estimate. In addition, trained medical personnel will
monitor the presenting features of the illness so that a „diagnosis‟ can be attached to the record.

1.2.4          Indicators for Monitoring Changes in the Health
               of the Population (Goal 1)
Anthropometric data, age-specific mortality and morbidity are used as core indicators of changes
in population health.

 Anthropometry

       Anthropometry, as well as morbidity, refers to the survivors rather than those who
       succumb to adverse health conditions. As such, anthropometric indices are extremely
       important indicators of early „health‟. Achieved size relative to size of a reference
       population remains a very useful indicator of environmental variables. These include
       dietary variables, exposure to infection, and care variables, all of which impact early
       physical development.

       The most useful anthropometric data includes growth data in narrow age windows of 6
       months to one year, length and weight scores. Length for age Z-score reflects the history
       of earlier physical growth; it is a very poor indicator of current conditions. Weight for
       age Z score is the composite of achieved length and current weight for length. Thus, it can
       reflect current as well as past conditions but cannot separate the two. Weight for length Z
       score is a very good indicator of current conditions.
       Therefore, it is preferable to examine length for age Z score and weight for length Z
       score.

       The methodology for weighing and measuring children under 5 is outlined in
       Appendix A3.

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 Mortality Monitoring

        One of the most desirable programme indicators is reduced young child mortality in the
        target populations. This is impossible to demonstrate in the given time frame of two
        years, but is considered an appropriate long-term goal (five years). As such, mortality
        monitoring will be included among the core indicators to be monitored in the baseline
        survey and again after five years in the cases of vitamin A interventions.

        A combination of the following methods will be used to monitor trends in mortality over
        a five-year period:

             where available, the estimation of death rates through routine registration of vital
              events, and National Health and Demographic Surveys;

             a short birth history to estimate mortality levels, trends and age-patterns prior to the
              intervention in the baseline survey;

             repeat the short birth history in conjunction with the five-year household survey, in
              order to estimate changes in mortality levels after the intervention; and

             add a „nesting‟ case-control study within this five-year household survey.



1.3 Selecting Indicators for Your Programme
Programme outcome and impact will be assessed over time in each region where interventions
are carried out, in order to measure programme effectiveness. When planning how to assess the
programmes, you should choose measurements which indicate relative progress. Before you
decide upon the indicators you will use, you need to:

   Identify specific micronutrient deficiencies
   Identify the target groups
   Select potential interventions to combat the deficiencies
   Recognize characteristics of a good indicator



1.3.1         Identify Specific Micronutrient Deficiencies
To begin the monitoring process, you must identify specific micronutrient deficiencies, based on
the analysis of your specific situation (review existing information of micronutrient problems in
the region). The MICAH programme focus is to improve nutritional status of at least three
micronutrients (iodine, vitamin A and iron), however this list is not exclusive.



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Other micronutrients, such as zinc, may be a more significant problem than iodine, vitamin A or
iron in some countries or regions, and thus should be focused on and monitored. The Programme
is also designed to improve health in general. For example, a reduction in morbidity as a result
of improved access to a clean water supply is a desirable Programme goal. As well, improved
micronutrient status as a result of reduced disease burden is also a valid goal.

How do you define areas with micronutrient deficiencies?

It is not likely that all regions of your country will have the same prevalence of micronutrient
deficiencies. By comparing existing data with international accepted standards, you can
determine the extent of the problem. For biological indicators, the international standards which
indicate the severity of vitamin A, iron and iodine deficiencies as a public health problem are
outlined in Appendix A4.


       Example

       Iron Indicators

       If 60% of women in a certain region have anaemia, a highly significant public health
       problem exists(WHO minimum prevalence of public health problem in population is
       5.0%).




       Example

       Vitamin A Indicators

       If the prevalence of Bitot‟s spots is 1.5% among children 6-71 months of age, vitamin A
       deficiency is a public health problem in that region (WHO minimum prevalence of public
       health problem in children is 0.5%).


If breast-milk retinol values are below 1.05 mol/l in more than 20% of the lactating women in a
certain region, vitamin A deficiency is considered a severe public health problem in that
population.




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       Example

       Iodine Indicators
       If 50% of school-aged children have goitre, a severe public health problem exists.
       If 25% of school-aged children have TSH >5mU/l, a moderate public health problem
       exists.

                                           
Develop your programmes in response
to the need. If iron deficiency is both
                                               Address micronutrient deficiencies that are of
severe and prevalent while vitamin A
                                               severe public health problem first.
deficiency is mild, iron would be
addressed. If vitamin A deficiency is
defined as a public health problem after
the situation analysis, address this micronutrient. The outcome/impact indicators must be
directly related to the specific micronutrient deficiency.
Remember, your goal is to target the most severe and prevalent micronutrient deficiencies.

1.3.2        Identify the Target Groups
The target group will also determine the indicator of choice. After you have defined the
geographic location of specific micronutrient deficiencies, the segment of the population with the
highest need for intervention programmes must be identified. Which group will your programme
„target‟? Target groups are usually defined as the „most vulnerable‟ groups.

Biologic vulnerability will significantly influence the selection of indicators when assessing
programme outputs/impact. Table 1.2 presents a framework to define the physiological groups
in which deficiencies are most likely to develop, and be prevented by an intervention. In your
community, other factors including patterns of disease and infection, as well as food use and
distribution trends will determine whether deficiency is likely in these vulnerable groups.
Women and children are the target groups for the MICAH programme.

However, for specific micronutrients, you should identify the most vulnerable group and age
within these larger groups.

       Example

       If you are targeting lactating mothers for vitamin A status, you can use breast milk
       vitamin A as an indicator, but not Bitot's spots. Breast milk is also a good indicator
       choice if your target group is infants between 0 and 6 months of age. However for
       children over 2 years of age, it is inappropriate.


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                 Table 1.2 Target Populations Defined in Relationship to Likely Vulnerability and Responsiveness


  Target Nutrient                   Vulnerable Period                                            Logical Target Group
  & Deficiency Effect
 IODINE                            Damage is likely in uteri,           Women of reproductive age. Intervention in pregnancy or infancy is too late to
 Disadvantageous effect            perhaps early in pregnancy.         improve mental development. *
 on mental development

 VITAMIN A                         Any age, risk greater in periods    Infants & young children. Prophylactic dosing as part of treatment protocols in
 Xerophthalmia and                 of rapid growth. Risk VERY high     health care centres.
 Blindness                         after measles infection.

 VITAMIN A                         As above. Relative risk             Children between 6 months & 6 yrs of age. There remains
 Function of immune                Considerations for mortality         concern about high potency dosing under 6 months.
 system //impact on                suggest equivalent benefit          Dose and time interval are critical if direct dosing.
 severe morbidity and              across gender and at all ages       Physiologic supplementation in lactation may be a safe way of
 mortality                         between 6 months and at least       reaching the infant while being breast fed (breast milk can be but is
                                   6 yrs. The absolute effect on       not necessarily, a good source of vitamin A).
                                   mortality is a function of age      Dosing during pregnancy is unlikely to have important beneficial
                                   -specific mortality rate, not       impact and high potency dosing runs a risk of teratogenicity.
                                   biological function of vitamin A.
                                   With improved sanitary
                                   Conditions and reduced
                                   Morbidity, effect of vitamin A
                                   might be expected to decrease
                                   (it is the same deaths that
                                   are being prevented).

 IRON                              The specific effects seem to         Specific target has to relate to complementary feeding of infants
 Iron deficiency anaemia           involve changes in the infant        with perhaps an important but smaller pathway from mother
 and impact on mental              under one year and have been         through milk (lactating mothers). Supplementation in pregnancy not likely to
 development                       linked to anaemia present           impact except through improved maternal iron stores.
                                   between about 4 and 8 months
                                   of age.

 IRON                              Pregnant women:                     Desirable approach would improve iron status of all women but
   Iron deficiency anaemia         Easily demonstrable risk            most frequent approach is direct supplementation during
   and maternal mortality          Associates with excessive           pregnancy.
   risk                            Bleeding in an anaemic woman


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  Target Nutrient                           Vulnerable Period                                                Logical Target Group
  & Deficiency Effect
                                           but there is also a
                                           documented (reversible??)
                                           association between anaemia
                                           and other unfavourable
                                           pregnancy outcomes.

 IRON                                      Clear evidence for maximal                Presumably all ages and both genders are affected. Therefore the
   Iron deficiency anaemia                 work performance (peak                    only targeting relates to presence or absence of anaemia.
   and work performance                    activity) and fairly good
                                           evidence for sustained working
                                           capacity ("productivity").

 *    Note that iodine differs from vitamin A and iron in that it is primarily a geographically defined disease (related to soil iodine content) and does not usually
      show major variation with income or cultural groupings except where these impact on access to and use of an iodine source such as iodized salt. Vitamin A
      and iron deficiencies are likely to more closely reflect specific food selection practices and exposures to infectious diseases and parasites.

Now you will have a more defined goal:

For example, to improve iron states of children under 5 years, and pregnant women.




EXCERPT FROM THE MICAH GUIDE                                                                                                                                PAGE 16
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1.3.3          Select Potential Interventions to Combat the
               Deficiencies
Interventions also determine the indicator chosen to monitor outcome and/or impact.
Consider the potential interventions that may be included in your programme. Table A.3 outlines
a non-exhaustive list of various interventions related to iron, iodine and vitamin A deficiencies.

 Example

 If the intervention is fortification of weaning food with vitamin A and iron, you would monitor
 the vitamin A status of children 6-24 months by looking at Bitot's spots, not breast milk
 vitamin A.

Programme approaches may vary according to specific country need: highly targetted vs
generalized, direct dosing, fortification, feeding, education etc. Think of the reasons why the
specific micronutrient deficiencies have occurred. These may include:

 poor access to or availability of micronutrients
 high prevalence of disease, decreasing micronutrient status
 poor capacity for agriculture and/or health care

The final selection of intervention strategies requires information regarding the potential
beneficiaries, specific problems, strengths of the local programme communities and the strategies
most appropriate to your situation.

Not all selected target populations will require interventions for all three micronutrients, since
operational programmes will vary with the specific country needs. However, a core set of
indicators will be collected at all sites (and periodically updated in all sites) for each
intervention, target group and micronutrient deficiency.



1.3.4        Recognize Characteristics of a Good Indicator
Indicators should be:

 readily quantifiable, using agreed-upon definitions and reference standards (ex. level of
  haemoglobin in blood, urinary iodine)
 acceptable to a given target population (ex. goitre examination)
 technically feasible (ex. Bitot‟s spots, breast milk collection)
 sensitive to changes over the time frame of the intervention (ex. Urinary iodine)
 specific (transferrin receptor)



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                             Table 1.3 Possible Types of Intervention


                   Intervention                                           Comment
                       IODINE

                Fortification:          Thinking to sustainability, preferred approach will be coordinated with
                Iodization of Salt      national and regional IDD Control plans - probably universal salt
                                        iodization.

                Supplementation:        For areas with severe deficiencies, where salt is unlikely for eating or
                Direct Supplements      unaffordable.

                     VITAMIN A

                Direct Supplements      Short-term solution through existing programmes (ex. EPI, schools)

                Food Fortification      Most successful if mandatory & universal fortification.

                Dietary Change          Sustainable. Budget allocation limits apply.(5%)

                Improve MOH             MOH services agent of implementation of other approaches.
                Services for Disease
                Prevention/Treatment

                Promote Breast          Must be coupled with action to ensure that lactating women have
                Feeding                 adequate micronutrient status.

                        IRON

                Direct supplement       Short-term. Must consider capacity.

                Food fortification      Consider possible impact of changing usual fortificant, including multiple
                                        fortificants. Probably need incentives for industry

                Dietary change          Sustainable budget restriction applies.

                Support MOH             Also see MOH as route for some other programmes.
                activities

                Promote Breast          Must be coupled with action to ensure that lactating women have
                Feeding                 adequate micronutrient status.




Indicators should also provide valid and reliable data. Validity means that the data actually
measure what they are supposed to measure. Reliability implies that measurement of an
indicator by different people at different times and under different circumstances yields
essentially similar results. Accurate measurements are close to true values. Inaccuracies may
occur due to imprecise instruments or to random variations in measurement techniques.




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1.4            Sources of Information for Indicators

1.4.1          Existing Data Sources
The information for the indicators from routinely collected statistics (e.g., routine health
information system (HIS)) or periodic national surveys (e.g., census data, demographic and
health surveys) may be used if considered reliable, representative of the intervention population
and within the correct time frame. The health information system and the census should be
reviewed first when looking for data to measure these indicators.

Health service statistics, however, are usually collected for administrative purposes, not for
monitoring purposes. Health service statistics can provide information on the number of patients
seen (with iron deficiency, for example), or the number of visits, but they rarely provide
information on the entire population at risk (for example, percentage of pregnant women with
iron deficiency anaemia), or the total population that is covered by the service.

Well-developed health information systems and good registers of vital events serve an important
complementary role: they supplement routine service statistics with timely data, which is not
usually collected in census and at service delivery points (SDPs). The programme should support
and enhance the health information systems, in addition to carrying out household surveys.


1.4.2          New Data
Household sample surveys are the most widely used method of providing data on health and
social indicators when other sources of data are deficient. However, household sample surveys
will not necessarily result in good information. The survey must be well designed with input
from experts in the fields of nutrition, health information systems, and statistics. Household-
based surveys are recommended because they will represent all households in a specified
geographic area, when performed correctly.

School-based surveys are recommended for monitoring indicators associated with iodine
deficiency (IDD) and helminth and other parasitic infections. School-aged children are a useful
group to monitor for IDD because they are highly vulnerable, easy to access, and useful for
various surveillance activities. Children with IDD develop an enlarged thyroid in response to
iodine deficiency and can be readily examined in large numbers in school settings over a short
period of time. We assume that at least 50% of the children in the intervention area attend
school.




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Focus groups and market surveys are other valuable ways of collecting information.
Surveys are the best source of data on programme coverage, and outcome/impact indicators of
nutrition and health programmes. They can provide breakdowns of information by regional,
social or ethnic groupings which are very difficult to obtain from routine data sources. Thus
household and school-based surveys are the recommended tool for collecting information on
indicators for the MICAH programme.



1.5 Levels of Monitoring Indicators
Since countries have various capacities to perform household surveys as outlined in this Guide,
three levels of monitoring are described. However, it is recommended that each participating
country aim for level „A‟, the first level of monitoring. Level A includes household and school
surveys, baseline and annual surveys, representative sampling, and the use of core indicators as
defined in the Guide. This is the most rigorous standard for monitoring and is the monitoring
method outlined in this guide.

Levels „B‟ and „C‟ differ from level A in that:

 in level „B‟, the indicators to be monitored differ from the core indicators outlined previously
  in this guide. The indicators are those which the particular government ministry is presently
  using to monitor micronutrient status.

 in level „C‟, the survey methodology used is case-control, rather than a representative
  household or school sampling.

Monitoring of process indicators at all three levels is still required.

1.5.1          Level A
      Indicators

       Core indicators as outlined previously in this guide and as relevant to your intervention.
       These include clinical, biochemical, anthropometric, dietary, mortality and morbidity
       indices.

      Sample Size and Population

       The samples should be large enough for a representative result, monitoring before-and-
       after change in populations covered by the programme. Areas of intervention should be
       combined and sampled as one area if the interventions are the same. If different
       interventions are being used, then you require separate samples.



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       Preferably, a sample should be drawn from the intervention areas and a control group
       sample from the non-intervention areas. If it is not possible to use a control group, then
       you will need national or regional standards, collected both pre and post intervention, to
       use as your comparison.

      Sampling Methodology

       Cross-sectional household surveys and school surveys with cluster and Probability
       Proportional to Size (PPS) sampling at village level. Alternatively weighting could be
       done at the time of data analysis.

      Frequency of Sampling

       Baseline and annually, depending on the indicator.



1.5.2         Level B
This level would be followed predominantly by programmes run by government ministries.

      Indicators

       These indicators include those which the particular government ministry is presently
       using to monitor micronutrient nutrition. It is unnecessary to include all of the core
       indicators outlined in this guide, if the country is using a different indicator to monitor
       one of the micronutrients.


       Example

       In Eritrea, the MOH monitors goitre and urinary iodine in school children to determine
       iodine status, serum ferritin in infants for iron status, and serum retinol in infants for
       vitamin A status. In this case, haemoglobin and breast milk retinol do not need to be
       monitored. Anthropometric measurements would not necessarily be required, but are still
       recommended.


      Sample Size and Population
       All intervention areas will be monitored. The sample size should be large enough for a
       70-80% confidence level in the intervention area. Before-and-after changes in the
       intervention populations must be monitored. A control group sampled from the non-
       intervention areas or national or regional data, collected both pre and post intervention are
       needed for comparison.


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      Example

      Vitamin A intervention in one area and iodine supplementation in another. Monitoring
      specific indicators for each intervention in all areas at baseline and annually should
      include an adequate sample size for measuring changes in both iodine and vitamin A
      status of the respective populations.

     Sampling Methodology

      Cross-sectional survey using schools and/or household is the method.

     Frequency of sampling

      Baseline and annually for the first 2 years.



1.5.3        Level C
This level would be adapted to programmes with minimal monitoring competency and would
stretch the limit of „plausible‟ measurement of impact.

     Sample Size and Population

      The sample population would be small, showing only some effect using the case-control
      method.

     Indicators

      The indicators would be outcome indicators, such as haemoglobin levels (of those
      coming to the health centres). The main indicators monitored in the intervention
      communities would be „process‟ indicators that identify input, activities and outputs (see
      below).

     Sampling Methodology

      A case control model measuring the outcome indicators in a sub-sample of the
      population.

     Sampling Frequency

      After one year of programme implementation, a case-control study will be completed.




EXCERPT FROM THE MICAH GUIDE                                                            PAGE 22
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A Final Note...
One of the most critical elements of the MICAH programme is measuring and understanding
impact. In the MICAH programme, we will evaluate impact at the level of plausibility to
determine if programmes seem to be having the effects we expect. In order to evaluate the
impact of programmes, both process and outcome/impact indicators must be measured. We have
stressed the importance of these indicators in this chapter, with a particular emphasis upon
outcome/impact indicators.

As you choose the appropriate indicators for your specific programme, remember to identify
specific micronutrient deficiencies, the target groups, and the intervention that will best combat
the deficiencies in these target groups.




1
    Methodology of Nutritional Surveillance, Technical Report Series 593. World Health Organization,
    Geneva, 1976.

2
    WHO/UNICEF. Indicators for assessing vitamin A deficiency and their application in monitoring and
    evaluating intervention programmes. Report of a joint WHO/UNICEF consultation, Geneva,
    Switzerland, 9-11 November 1992. Review version, May 1994.

3
    WHO/UNICEF/ICCIDD. Indicators for assessing iodine deficiency disorders and their control through
    salt iodization.




EXCERPT FROM THE MICAH GUIDE                                                                     PAGE 23
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           Appendix A-1

  Flow Charts for
Vitamin A, Iodine &
 Iron Deficiencies


EXCERPT FROM THE MICAH GUIDE   Page 24   APPENDIX A
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   Objective                                                 1.1 Decrease Vitamin A
                                                                 Deficiencies




   Strategies               Supplementation                            Fortification                          Food
                                                                                                          Diversification




   Target       Lactating             Children          All (monitor in          Children (6 –   Pregnant and         Children (6 –
   Groups       Women                 (6 – 59 months)   women pregnant           24 months)      lactating            25 months)
                                                        and lactating)                           women




   Outcome      Xerophthalmia        Xerophthalmia       Xerophthalmia           Xerophthalmia   Xerophthalmia      Xerophthalmia
   Indicators




                Breast milk          Serum retinol       Breast milk             Serum retinol   Breast milk        Serum retinol
Note:
                Vit. A                                   Vit. A                                  Vit. A
Primary
Indicator

Secondary
Indicator       Serum retinol                            Dietary                 Dietary         Dietary            Dietary
                                                         assessment              assessment      assessment         assessment




    EXCERPT FROM THE MICAH GUIDE              Page 25                              APPENDIX A
    WORLD VISION CANADA
Objective                                                         1.2 Decrease Iodine
                                                                      Deficiencies




Strategies                                      Supplementation                             Food
                                                                                        Diversification




Target              Pregnant &                   Neonates              School Aged      UNTARGETED
Groups              Lactating                                          Children
                    Women


Outcome             Goitre                      TSH                    Goitre           Goitre (high
Indicators          (<30 years)                                        (6 – 12 years)   prevalence
                                                                                        areas)



                    Urinary Iodine                                     Urinary Iodine   Urinary Iodine
                                                                                        (high prevalence
                                                                                        areas)
Note:

Primary             Thyroid hormone
                    levels (Tg)                                                         TSH, Tg (low
Indicator
                                                                                        prevalence
                                                                                        areas)
Secondary
Indicator

                                                                                        Diet: amount
                                                                                        and kind of salt
                                                                                        consumed
EXCERPT FROM THE MICAH GUIDE          Page 26                        APPENDIX A
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EXCERPT FROM THE MICAH GUIDE   Page 27   APPENDIX A
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           Appendix A-2

        Methodology to
           Determine
         Indicators for
      Vitamin A, Iodine &
       Iron Deficiencies




EXCERPT FROM THE MICAH GUIDE   Page 28   APPENDIX A
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          BIOCHEMICAL METHODS, SOURCE OF EQUIPMENT AND COST

1. IRON INDEX:

Haemoglobin (CORE INDICATOR):

Method A: The HemoCue system is the preferred quantitative cyanmethaemoglobin (HbCN)
method for field use. In this system sodium azide is added to undiluted blood to form
methaemoglobin azide. The system, consists of a battery-operated photometer and a disposable
sodium azide-coated cuvette which also serves as a blood collection device. It is uniquely suited
for rapid field surveys because of the one-step blood collection does not require liquid reagents.
Non-laboratory personnel can easily be trained to operate the device and it is not dependent on
electricity. (From „Indicators and Strategies for iron deficiency and anaemia programmes‟
WHO/UNICEF/UNU Consultation, Geneva, 1993)

The HemoCue system is reported to have good accuracy (±1.5%) and precision (0.99 correlation)
when evaluated against standard laboratory methods (Johns WL, Lewis SM: Primary health
screening haemoglobinometry in a tropical community. Bulletin WHO 1989;67:627-33.) Long
term field experience has also shown the instrument to be stable and durable. These features
make it the method preferred for the MICAH repeated nutrition surveys.

Even though the HemoCue is a suitable instrument for field surveys, the relatively high cost of
the disposable cuvette makes its routine use unlikely for clinical services in primary health care
clinics in resource-poor settings. The recommendation for use between evaluations of the impact
of iron programmes, is to take advantage of the long term stability of the HemoCue system for
quality assurance comparison with other Hb methods used by primary health care clinics.

Cost: A sampling of 300 women per population would cost about 300 x 1.00/sample = 300 USD.

Diagnosis of iron deficiency: One established approach to diagnose iron deficiency in a
population is to monitor changes in Hb after oral iron supplementation. An increase of at least
10 g/l in Hb after one or two months of supplementation is diagnostic for iron deficiency.
(Indicators and strategies for iron deficiency and anaemia programmes. WHO/UNICEF/UNU
Consultation, 1993). This may be a less expensive diagnosis of iron deficiency than using
transferrin receptor, assuming that the population has actually consumed the oral iron
supplements.




EXCERPT FROM THE MICAH GUIDE                         Page 29                          APPENDIX A
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Hemocue:
To order directly from Africa, the orders can go through the office in Sweden, Tanzania or South
Africa:

Ms. Birgitta Haggren
Sales & Marketing Dept
Box 1204
S-26223 Angelholm
Sweden

Tel: 46-431-58200
Fax: 46-431-83035

Medilab Ltd
PO Box 525
Dar Es Salaam, Tanzania

Phone: 255-51-28192/36670
Fax: 255-51 116711/37188

Trigate Pty Ltd
PO Box 2240
Randburg 2125
South Africa

Phone: 27-11-886 1830
Fax: 27-11 996 3569

Cost:                 Haemoglobin Photometer:       CAD 550
Microcuvettes:        CAD 60 per 200

Terms of payment: 30 days net after invoice date
Time of delivery: 1-2 working weeks after receipt of firm order
Way of delivery: Airfreight or UPS
Air freight cost for one photometer and one package of cuvettes (from Sweden): CAD 265

Method B. Hemaglobinometer:
The only colour matching method with an acceptable level of accuracy is the BMS
haemoglobinometer. In this test, blood is lysed, the haemoglobin converted to oxyhemoglobin
and compared in a hand-held photometer with a standard coloured glass wedge.




EXCERPT FROM THE MICAH GUIDE                        Page 30                         APPENDIX A
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South Africa source:

SAMTREX (PTY) Ltd.
PO Box 10409
Johannesburg 2000
Tel: (2711) 622-2613
Fax: (2711) 615-8114

Cost:          Haemoglobinotmeter:       SAR 970 (USD 280)
Cuvettes:      SAR 45 per 100 (4.5ml; 10mm path length)


Transferrin Receptor (TR)

TR is an additional indicator which may be used to diagnose iron deficiency in the population
where there are multiple causes of anaemia. An increase in TR is a sensitive response during the
early development of iron deficiency. TR levels increase progressively as iron stores approach
exhaustion just prior to the onset of anaemia. Major advantages of measuring TR are that the
assay is not significantly affected by infection or inflammatory processes and does not vary with
age, sex or pregnancy. The mean level in normal subjects using the ELISA method is 5.6 mg/l
with a range of 2.8-8.5 mg/l.

Method: The method is an Enzyme Immunoassay (EIA) based on the double antibody sandwich
method. The method requires very small amounts (10ul) of plasma or serum and will need to be
carried out in a lab and by qualified technicians.

Cost: About 100 samples are all that are necessary to verify if a population has iron deficiency
anaemia. The cost of 40 samples is about 500 USD, thus the cost of 120 samples is USD 1,500.

Equipment needed: Additional equipment needed is a microplate reader capable of reading at
450 nm. A multi-channel pipetter is recommended.

Main Distributer of commercial kits (produced by Ramco, USA):

Ethiopia and Eritirea can order from (allow 2-3 weeks for delivery):

Ramco Laboratories Inc.
4507 Mt. Vernon
Houston, Texas
U.S.A. 77006

Tel: (713) 526-9677
1-800-231-6238
Fax: (713) 526-1528



EXCERPT FROM THE MICAH GUIDE                         Page 31                         APPENDIX A
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Catalog Number: TF-94
Price/Kit: USD 500 (not including shipping, handling and customs charges)
Tests per Kit: Maximum 40 test/kit if performed at one time
Assay type: EIA
Format:        Microplate)
Sensitivity: 0.07 ug/ml
Expected Values:     5.6 + 1.45 ug/ml


Malawi and Mozambique can order the same kit from Ramco distributor in SA:

Weil Organisation (PTY) Ltd
PO Box 1596
Kelvin 2054
South Africa

Tel: +27-11-444-4330
Fax: +27-11-444-5457

Approximate price per kit is SAR 2900 (USD 840), delivered C&F to either Blantrye or Maputo.
 Availability is within 14-21 days from receipt of firm order and once a method of payment has
been established.

2. IODINE INDICES:

Urinary Iodine (CORE INDICATOR)

Recommended method for determining iodine in urine:

Method described in the Annex 4, p.53 of „Indicators for assessing Iodine Deficiency Disorders
and their control through salt iodization‟. Urine is digested with chloric acid under mild
conditions and iodine determined manually by its catalytic role in the reduction of ferric
ammonium sulfate in the presence of arsenious acid. The method described is fast and
inexpensive. The method determines urinary iodine concentrations in the range of 0-150 ug/l (0-
1.19 umol/l), but can be expanded to cover a wider range of values.

Equipment needed: Heating block, colorimeter (or simple spectrophotometer, vented fume hood
with perchloric acid trap, thermometer, test tubes, reagent flasks and bottles, pipettes and a
laboratory balance.

Need to include collection containers and transport to central laboratory (do not need to be
refrigerated in transport) for analysis in the cost of the test. E.g., Collection tubes with screw
tops, such as Sarstedt tubes (no. 60542).




EXCERPT FROM THE MICAH GUIDE                           Page 32                           APPENDIX A
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Cost: Total estimated costs per specimen is USD1.00, including labour. The cost increases to
USD 3.50 per sample if they are analysed at CDC in Atlanta. I am presuming that all countries
have the lab capacity for this analysis and can access the lab. Is this correct?

Number: About 300 samples from a given population group need to be analysed. Thus allow
USD 1.00 x 300 = USD 300 per population group. For quality control, 30-40 samples can be
sent to CDC in Atlanta, for the cost of USD 140 (shipping and handling not included).


Thyroid Stimulation Hormone (TSH)

Method: TSH in the blood spot can be measured by commercially available assay kits. The
enzyme-linked immunosorbant assay (ELISA) methodology is recommended because of lower
equipment cost, longer shelf life of reagents (6 months) and high sensitivity (<2 mU/l).

Transport: Blood spots are easy to transport. The spot must be dry before storage or shipment.
Whole blood from any site is acceptable for spotting on to certified grade 1 filter paper. Filter
papers, usually stored in a plastic bag, can be transported using the normal postal system and are
stable for periods of up to 6 weeks even in a hostile environment of high temperature and
humidity.

Cost: Estimated costs if done in country are USD 1.00/test, not including labour or initial
laboratory equipment set-up costs. Cost is USD 2.50 per sample if they are analysed at CDC in
Atlanta. Laboratories should participate in an external quality control programme. About 300
samples are needed per population group, thus, USD 300 + cost of external control (USD 100) =
400 USD.

Other equipment needed: Gloves, TSH ELISA laboratory hardware and software capable of
processing up to 5,000 tests/year/technologist USD 5,000.

Iodized Salt

Commercial field spot test kits manufactured by MBI Chemicals, Madras, India, are available for
procurement through UNICEF. HOWEVER, WORLD VISION OFFICES MAKE ALL
REQUESTS FOR INFORMATION AND PURCHASING FROM UNICEF COPENHAGEN
THROUGH THE WV INTERNATIONAL OFFICE.

WV International
Bob Wilson, Purchasing Manager
Fax (818) 301-7786
Phone (818) 303-8811




EXCERPT FROM THE MICAH GUIDE                          Page 33                         APPENDIX A
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Ordering information:

Field Test Kits for the determination of potassium IODATE in iodized salt samples:

       UNICEF STOCK NO.: 05-860-00 (For range 0-50 ppm)

       UNICEF STOCK NO.: 05-860-01 (for range 0-100 ppm)

Field Test Kit for the determination of potassium IODIDE in iodized salt samples:

       UNICEF STOCK NO.: 05-860-02

NOTE:
1. There are two types of kits available for salt fortified with potassium iodate or potassium
iodide. The type needed must be specified when ordering.

2. The standard kit is designed to check the presence of iodine in salt (fortified with potassium
iodate) over the range of 0-50 ppm and consists of two ampoules of the test solution (10 ml in
each ampoule, sufficient for 40-50 tests), packed in a cloth pouch along with a stainless steel
spoon and plate, colour chart and instruction notes.

3. For countries setting iodine dosage in salt at 100 ppm, MBI offers an alternate test kit. The
test solutions show colour contrast for iodine content up to 100 ppm.

4. The solutions have a shelf life of more than eighteen months if unopened and 6 months after
opening the ampoule.

5. Refill ampoules (10) are available in cardboard boxes along with a colour chart and manual.

Sample Size

Sample size = 769 households; assuming 50% proportion of households with iodized salt, 95%
confidence level, confidence width of ±5%, design effect of 2, (see p.72 of Monitoring Universal
Salt Iodization)

Cost

Pouch containing 2 test ampoules, plate and spoon, colour chart and instructions is CAD 2.50
(this is adequate for 80-100 tests). Thus, 2.50 x 10 = 25.00 CAD.

Delivery Time

MBI advises that a delivery lead time of 4-8 weeks may be assumed from the time an order is
placed.



EXCERPT FROM THE MICAH GUIDE                          Page 34                          APPENDIX A
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3. VITAMIN A INDICATORS

Breast Milk Vitamin A Concentration

Breast milk vitamin A concentration is a unique indicator of vitamin A status because it provides
information about the vitamin A status of the mother and the breast-fed infant. The mother‟s
secretion of vitamin A into milk is directly related to her vitamin A status, at least when her
vitamin A status is inadequate. It is not affected by infection, as is serum retinol.

Milk samples should be collected from mothers 1-8 months postpartum, which means that
colostrum and transitional milk are avoided. During this period, breast milk proximate
composition is relatively stable and is likely to provide the major source of dietary vitamin A for
the infant, with complementary foods contributing little.

When interpreted on a population basis, it is not necessary to control the time of day of sample
collection or the time since the infant was last breast-fed. (Indicators for assessing vitamin A
deficiency and their application in monitoring and evaluating intervention programmes.
WHO/UNICEF Consultation, Geneva, 1994).

Method: The recommended method is to determine the concentration of vitamin A in milk by
HPLC (alternately, a spectrophotometric method, or fluormentric method can be used).

Cost: Cost depends on the analytical method used and whether or not the samples need to be
sent outside the country. If a HPLC system needs to be purchased it will cost between
USD15,000 - USD40,000, just for the system. In addition are the costs of a column (USD500),
column guard (USD75), solvents, upkeep of system, etc.

If there are no facilities within the country at the time of the survey, the samples should be sent to
a lab in Africa. At present, the only lab identified in Africa which routinely does breast milk
vitamin A analyses is one at the Noguchi Memorial Institute for Medical Research, University of
Ghana. The contact person is Dr. Takyi, noted below. Cost of analysis per sample is USD 10.00.

Collection and Transport: Milk samples can be obtained by manual expression or by using a
simple breast pump. A 5 ml sample from only one breast is sufficient. Sample must be collected
into amber tubes (or protected from light with tin foil) or vials with air-tight caps. The samples
can be transported on ice to the laboratory for aliquoting and stored in a freezer at -20C.

Samples need to be shipped by air, consigned to CIDA or similar Agency in Ghana to make
clearance easy. The samples must be frozen before airfreight and require proper packaging with
ice packs or dry ice during airfreight to ensure that they remain frozen.




EXCERPT FROM THE MICAH GUIDE                           Page 35                           APPENDIX A
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Ghana:

Dr. E.E.K. Takyi
Biochemist/Nutritionist & Senior Research Fellow
Noguchi Memorial Institute of Medical Research
University of Ghana
PO Box 25
Legon
Ghana

Fax: (233) 21 502182
E-mail: Noguchi@gha.healthnet.org
Phone: (233) 21 500374

South Africa:

As of 06/96, they have a HPLC methodology in place for the determination of retinol and alpha-
tocopherol in plasma or serum, but not yet for breast milk. They plan to set up a method for
breast milk in the near future.

Contact person:

Ms ME van Stuijvenberg
National Research Programme for Nutritional Intervention
South African Medical Research Council
PO Box 19070
Typerberg 7505
South Africa
Tel (021) 938-0264
Fax (021) 938-0321
E-mail lvanstui@eagle.mrc.ac.za


PARASITOLOGY INDICES:

Contact person:

Dr. L Savioli,
Programme of Intestinal Parasitic Infections
Division of Emerging, Viral and Bacterial Diseases Surveillance and Control
WHO
1211 Geneva 27
Switzerland
Fax: (41 22) 791 4198



EXCERPT FROM THE MICAH GUIDE                       Page 36                         APPENDIX A
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ANTHROPOMETRIC INDICES:

1. Weight
Scales: UNICEF UNIscale - solar/battery operated standing scale: USD 96.00

2. Height/Length
Length/height board: UNICEF wood model , weight of 6 kg, measures children up to 130 cm
Cost: USD 290

Ordering for the UNICEF equipment noted above is made through the WV International Office:

Bob Wilson, Purchasing Manager
WV International
Fax (818) 301-7786
Phone (818) 303-8811


LABORATORY HELP:

1. TRAINING

PAMM is helping to develop in-country training capacity in micronutrients - in ongoing regional
and national educational systems. They would be willing to work on this collaboratively. For
further information contact:

Dair Brown
Logistics Coordinator
PAMM
1518 Clifton Road, NE
Atlanta, GA
30322

Tel: (404) 727-5416
Fax: (404) 727-4590




EXCERPT FROM THE MICAH GUIDE                        Page 37                        APPENDIX A
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2. SAMPLE CROSS-CHECK AND QUALITY CONTROL VALIDATION:

Contact Warwick May to arrange for PAMM/CDC to do a sample cross-check and QC validation
at the following address:

Warwick May, Micronutrient Analysis
PAMM Laboratory
Centre for Disease Control and Prevention 4770 Buford Hway, NE
Mailstop F-20
Atlanta, GA
30341
Tel: (770) 488-4088
Fax: (770) 488-4609
E-mail: wam4@CEHEHL1.EM.CDC.GOV


3. OTHER LABS IN AFRICA DOING MICRONUTRIENT ANALYSES
(Please add to the list, the labs in your country.)

Vincent Assey
Tanzania Food and Nutrition Centre
Tel: 255-51-29621-3
Fax: 255-51-28951
E-mail: TFNC@Tan.healthnet.org

Ebenezer Asibey-Berko
Dept Nutrition and Food Science
Univ Ghana
Fax: 233-21-226-736
Internet[Balme@ug.apc.org]

Ebert Oosthuysen
Medical Lab Services
Windhoek Central Hospital
Windhoek, Namibia
Tel: 264-61-203-2592
Fax: 264-61-233-285

Ada Fatime Ezeogu
Dept Chemical Pathology
Faculty Medical sciences
Univ of Jos
Nigeria
Tel/Fax: 234-73-526-89



EXCERPT FROM THE MICAH GUIDE                     Page 38                    APPENDIX A
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Theodora Nyamandi
The Govt Analyst Laboratory
Box 8042
The Causeway
Harare, Zimbabwe
Tel: 263-4-792-026
Fax: 263-4-702-293

Peter Jooste, Mike Weight (iodine), Lize van Stuivenberg (VA) NRPNI
SA Medical Research Council, Tygerberg, South Africa
Tel: 021-938-0265
Fax: 021-938-0321
E-mail: MWEIGHT@EAGLE.MRC.AC.ZA




EXCERPT FROM THE MICAH GUIDE                     Page 39              APPENDIX A
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           Appendix A-3

   Methodology for
     Weighing &
  Measuring Children



EXCERPT FROM THE MICAH GUIDE   Page 40   APPENDIX A
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The following material is reprinted from Annex 1, “Summary Procedures”, of HOW TO WEIGH
AND MEASURE CHILDREN: ASSESSING THE NUTRITIONAL STATUS OF YOUNG
CHILDREN IN HOUSEHOLD SURVEYS, prepared by the United Nations Department of
Technical Co-operation for Development and Statistical Office, New York, 1986.




Precautions Before Measuring

A.    Layout of the Procedures
      Each step of the measurement procedures is directed at specific participants, who are
      named in bold letters at the beginning of each step: e.g. “Measurer”, “Assistant”, etc.

B.    Two Trained People Required
      Two trained people are required to measure a child‟s height and length. The measurer
      holds the child and takes the measurements. The assistant helps hold the child and
      records the measurements on the questionnaire. If there is an untrained assistant, such as
      the mother, then the trained measurer should also record the measurements on the
      questionnaire. One person alone can take the weight or arm circumference of a child and
      record the results if an assistant is not available.

C.    Measuring Board and Scale Placement
      Begin to observe possible places where the board can be positioned and the scale hung as
      soon as you walk towards a sample household. Be selective about where you place the
      measuring board and scale. It is best to measure outdoors during daylight hours. If it is
      cold, raining or if too many people congregate and interfere with the measurements, it
      may be more comfortable to weigh and measure a child indoors. Make sure there is
      adequate light.

D.    Age Assessment
      Before you measure, determine the child‟s age. If the child is less than two years,
      measure length. If the child is two years of age or older, measure height (see Annex C).
      If accurate age is not possible to obtain, measure length if the child is less than 85 cm.
      Measure height if the child is equal to or greater than 85 cm.




EXCERPT FROM THE MICAH GUIDE                        Page 41                          APPENDIX A
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E.    When to Weigh and Measure
      Weigh and measure after verbal information has been recorded on the questionnaire.
      This will allow you to become familiar with the members of the household. DO NOT
      weigh and measure at the beginning of the interview, i.e. as soon as you enter a
      household, which would be more of an upsetting intrusion.

F.    Weigh and Measure One Child at a Time
      If there is more than one eligible child in a household, complete the entire questionnaire,
      including the weighing and measuring of one child. Then proceed with the next eligible
      child‟s questionnaire in the household. DO NOT weigh and measure all the children
      together. This can easily cause confusion and will create a greater chance for error, such
      as recording one child‟s measurements on another child‟s questionnaire. Return
      measuring equipment to their storage bags immediately after you complete the
      measurements for each household.

G.    Control the Child
      When you weigh and measure, you must control the child. The strength and mobility of
      even very young children should not be underestimated. Be firm, yet gentle, with
      children. Your own sense of calm and self confidence will be felt by the mother and the
      child.

      When a child has contact with any measuring equipment, i.e. on a measuring board, in the
      weighing pants or with an arm circumference tape, you must hold and control the child so
      the child will not trip or fall. Never leave a child alone with a piece of equipment.
      Always have physical contact with the child, except when you must let go of a child for a
      few seconds while taking the weight.


H.    Coping with Stress
      Since weighing and measuring requires touching and handling children, normal stress
      levels for this type of survey work are higher than for surveys where only verbal
      information is collected.

      Explain the weighing and measuring procedures to the mother, and to a limited extent, the
      child, to help minimize possible resistance, fears or discomfort they may feel. You must
      determine if the child or mother is under so much stress that the weighing and measuring
      must stop. Remember, young children are often uncooperative; they tend to cry, scream,
      kick and sometimes bite. If a child is under severe stress and is crying excessively, try to
      calm the child or return the child to the mother for a moment before proceeding with the
      weighing and measuring.

EXCERPT FROM THE MICAH GUIDE                        Page 42                           APPENDIX A
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      Do not weigh or measure a child if:

      a.     The mother refuses.
      b.     The child is too sick or too distressed.
      c.     The child is physically deformed, which will interfere with or give an incorrect
             measurement. To be kind, you may want to measure such a child and make a note
             of the deformity on the questionnaire.

I.    Recording Measurements and Being Careful
      Record the measurements in pencil. If you make an error, completely erase the error and
      rewrite the correct numbers. Keep objects out of your hands and pencils out of your
      mouth, hair or breast pocket when you weigh and measure so that neither the child nor
      you will get hurt due to carelessness. When you are not using a pencil, place it in your
      equipment pack, pencil case or on the survey form. Make sure you do not have long
      fingernails. Remove interfering rings and watches before you weigh and measure. Do
      not smoke when you are in a household or when you weigh and measure.

J.    Strive for Improvement
      You can be an expert measurer if you strive for improvement and follow every step of
      every procedure the same way every time. The quality and speed of your measurements
      will improve with practice. You may be working with a partner to form a team. If so,
      you will be responsible for not only your own work, but also for the quality of work of
      your team.

      You will be required to weigh and measure many children. Do not take these procedures
      for granted even though they may seem simple and repetitious. It is easy to make errors
      when you are not careful. Do not omit any steps. Concentrate on what you are doing.




EXCERPT FROM THE MICAH GUIDE                       Page 43                         APPENDIX A
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II. Nutritional Status Measurement Summary
    Procedures
A.    Child Height Summary Procedure (Illustration 1)*

      1.    Measurer or Assistant:

            Place the measuring board on a hard flat surface against a wall, table, tree,
            staircase, etc. Make sure the board is stable.

      2.    Measurer or Assistant:

            Ask the mother to remove the child‟s shoes and unbraid any hair that would
            interfere with the height measurement. Ask her to walk the child to the board and
            to kneel in front of the child (if she is not the assistant).

      3.    Assistant:

            Place the questionnaire and pencil on the ground (Arrow 1). Kneel with both
            knees on the right side of the child (Arrow 2).

      4.    Measurer:

            Kneel on your right knee only, for maximum mobility, on the child‟s left side
            (Arrow 3).

      5.    Assistant:

            Place the child‟s feet flat and together in the centre of and against the back and
            base of the board. Place your right hand just above the child‟s ankles on the shins
            (Arrow 4), your left hand on the child‟s knees (Arrow 5) and push against the
            board. Make sure the child‟s legs are straight and the heels and calves are against
            the board (Arrows 6 and 7). Tell the measurer when you have completed
            positioning the feet and legs.

      6.    Measurer:

            Tell the child to look straight ahead at the mother if she is in front of the child.
            Make sure the child‟s line of sight is level with the ground (Arrow 8). Place your
            open left hand on the child‟s chin. Gradually close your hand (Arrow 9). Do not
            cover the child‟s mouth or ears.



EXCERPT FROM THE MICAH GUIDE                       Page 44                           APPENDIX A
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               Make sure the shoulders are level (Arrow 10), the hands are at the child‟s side
               (Arrow 11), and the head, shoulder blades and buttocks are against the board
               (Arrows 12, 13, and 14). With your right hand, lower the headpiece on top of the
               child‟s head. Make sure you push through the child‟s hair (Arrow 15).

       7.      Measurer and Assistant:

               Check the child‟s position (Arrows 1-15). Repeat any steps as necessary.

       8.      Measurer:

               When the child‟s position is correct, read and call out the measurement to the
               nearest 0.1 cm. Remove the headpiece from the child‟s head, your left hand from
               the child‟s chin and support the child during the recording.

       9.      Assistant:

               Immediately record the measurement and show it to the measurer.
               NOTE: If the assistant is untrained, the measurer records the height.

       10.     Measurer:

               Check the recorded measurement on the questionnaire for accuracy and legibility.
               Instruct the assistant to erase and correct any errors.




__________________
*     If the assistant is untrained, e.g. the mother, then the measurer should help the assistant
      with the height procedure.




EXCERPT FROM THE MICAH GUIDE                          Page 45                          APPENDIX A
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EXCERPT FROM THE MICAH GUIDE   Page 46   APPENDIX A
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B.    Child Length Summary Procedure (Illustration 2)*

      1.    Measurer or Assistant:

            Place the measuring board on a hard flat surface, i.e. ground, floor or steady table.

      2.    Assistant:

            Place the questionnaire and pencil on the ground, floor or table (Arrow 1). Kneel
            with both knees behind the base of the board, if it is on the ground or floor
            (Arrow 2).

      3.    Measurer:

            Kneel on the right side of the child so that you can hold the footpiece with your
            right hand (Arrow 3).

      4.    Measurer and Assistant:

            With the mother‟s help, lie the child on the board by doing the following:

            Assistant:

            Support the back of the child‟s head with your hands and gradually lower the child
            onto the board.

            Measurer:

            Support the child at the trunk of the body.

      5.    Measurer or Assistant:

            If she is not the assistant, ask the mother to kneel on the opposite side of the board
            facing the measurer to help keep the child calm.

      6.    Assistant:

            Cup your hands over the child‟s ears (Arrow 4). With your arms comfortably
            straight (Arrow 5), place the child‟s head against the base of the board so that the
            child is looking straight up. The child‟s line of sight should be perpendicular to
            the ground (Arrow 6). Your head should be straight over the child‟s head. Look
            directly into the child‟s eyes.




EXCERPT FROM THE MICAH GUIDE                       Page 47                           APPENDIX A
WORLD VISION CANADA
       7.      Measurer:

               Make sure the child is lying flat and in the centre of the board (Arrows 7). Place
               your left hand on the child‟s shins (above the ankles) or on the knees (Arrow 8).
               Press them firmly against the board. With your right hand, place the footpiece
               firmly against the child‟s heels (Arrow 9).

       8.      Measurer and Assistant:

               Check the child‟s position (Arrows 1-9). Repeat any steps as necessary.

       9.      Measurer:

               When the child‟s position is correct, read and call out the measurement to the
               nearest 0.1 cm. Remove the footpiece, release your left hand from the child‟s
               shins or knees and support the child during the recording.

       10.     Assistant:

               Immediately release the child‟s head, record the measurement, and show it to the
               measurer.

               NOTE: If the assistant is untrained, the measurer records the length on the
               questionnaire.

       11.     Measurer:

               Check the recorded measurement on the questionnaire for accuracy and legibility.
               Instruct the assistant to erase and correct any errors.


_________________
*     If the assistant is untrained, e.g. the mother, then the measurer should help the assistant
      with the length procedure.




EXCERPT FROM THE MICAH GUIDE                          Page 48                          APPENDIX A
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EXCERPT FROM THE MICAH GUIDE   Page 49   APPENDIX A
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C.    Child Weight Summary Procedure (Illustration 3)*

      1.    Measurer or Assistant:

            Hang the scale from a tree branch, ceiling beam, tripod or pole held by two
            people. You may need a piece of rope to hang the scale at eye level. Ask the
            mother to undress the child.

      2.    Measurer:

            Attach a pair of the empty weighing pants, infant sling or basket to the hook of the
            scale and adjust the scale to zero, then remove from the scale.

      3.    Measurer:

            Have the mother hold the child. Put your arms through the leg holes of the pants
            (Arrow 1). Grasp the child‟s feet and pull the legs through the leg holes (Arrow
            2). Make certain the strap of the pants is in front of the child.

      4.    Measurer:

            Attach the strap of the pants to the hook of the scale. DO NOT CARRY THE
            CHILD BY THE STRAP ONLY. Gently lower the child and allow the child to
            hang freely (Arrow 3).

      5.    Assistant:

            Stand behind and to one side of the measurer ready to record the measurement.
            Have the questionnaire ready (Arrow 4).

      6.    Measurer and Assistant:

            Check the child‟s position. Make sure the child is hanging freely and not touching
            anything. Repeat any steps as necessary.

      7.    Measurer:

            Hold the scale and read the weight to the nearest 0.1 kg. (Arrow 5). Call out the
            measurement when the child is still and the scale needle is stationary. Even
            children who are very active, which causes the needle to wobble greatly, will
            become still long enough to take a reading. WAIT FOR THE NEEDLE TO
            STOP MOVING.




EXCERPT FROM THE MICAH GUIDE                      Page 50                          APPENDIX A
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       8.     Assistant:

              Immediately record the measurement and show it to the measurer.

       9.     Measurer:

              As the assistant records the measurement, hold the child in one arm and gently lift
              the child by the body. DO NOT LIFT THE CHILD BY THE STRAP OF THE
              WEIGHING PANTS. Release the strap from the hook of the scale with your free
              hand.

       10.    Measurer:

              Check the recorded measurement on the questionnaire for accuracy and legibility.
              Instruct the assistant to erase and correct any errors.



__________________
*     If the assistant is untrained, e.g. the mother, then weight should be taken by one person
      only, the trained measurer, who should also record the measurement on the questionnaire.




EXCERPT FROM THE MICAH GUIDE                        Page 51                          APPENDIX A
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EXCERPT FROM THE MICAH GUIDE   Page 52   APPENDIX A
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D.    Child Mid-Upper Arm Circumference Summary Procedure
      (MUAC) (Illustration 4)*

      1.    Measurer:

            Keep your work at eye level. Sit down when possible. Very young children can
            be held by the mother during this procedure. Ask the mother to remove clothing
            that may cover the child‟s left arm.

      2.    Measurer:

            Calculate the midpoint of the child‟s left upper arm by first locating the tip of the
            child‟s shoulder (Arrows 1 and 2) with your fingertips. Bend the child‟s elbow to
            make a right angle (Arrow 3). Place the tape at zero, which is indicated by two
            arrows, on the tip of the shoulder (Arrow 4) and pull the tape straight down past
            the tip of the elbow (Arrow 5). Read the number at the tip of the elbow to the
            nearest centimetre. Divide this number by two to estimate the midpoint. As an
            alternative, bend the tape up to the middle length to estimate the midpoint. A
            piece of string can also be used for this purpose. Either you or an assistant can
            mark the midpoint with a pen on the arm (Arrow 6).

      3.    Measurer:

            Straighten the child‟s arm and wrap the tape around the arm at the midpoint.
            Make sure the numbers are right side up. Make sure the tape is flat around the
            skin (Arrow 7).

      4.    Measurer and Assistant:

            Inspect the tension of the tape on the child‟s arm. Make sure the tape has the
            proper tension (Arrow 7) and is not too tight or too loose (Arrows 8-9). Repeat
            any steps as necessary.

      5.    Assistant:

            Have the questionnaire ready.

      6.    Measurer:

            When the tape is in the correct position on the arm with the correct tension, read
            and call out the measurement to the nearest 0.1 cm. (Arrow 10).




EXCERPT FROM THE MICAH GUIDE                       Page 53                           APPENDIX A
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       7.     Assistant:

              Immediately record the measurement on the questionnaire and show it to the
              measurer.

       8.     Measurer:

              While the assistant records the measurement, loosen the tape on the child‟s arm.

       9.     Measurer:

              Check the recorded measurement on the questionnaire for accuracy and legibility.
              Instruct the assistant to erase and correct any errors.

       10.    Measurer:

              Remove the tape from the child‟s arm.



___________________
*     If the assistant is untrained, e.g. the mother, then arm circumference should be measured
      by one person only, the trained measurer, who should also record the measurement on the
      questionnaire.




EXCERPT FROM THE MICAH GUIDE                        Page 54                         APPENDIX A
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EXCERPT FROM THE MICAH GUIDE   Page 55   APPENDIX A
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           Appendix A-4

International Standards
          for
   Vitamin A, Iron &
  Iodine Deficiencies



EXCERPT FROM THE MICAH GUIDE   Page 56   APPENDIX A
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                        Standards for Vitamin A Deficiency

              Biological Indicators of Clinical Vitamin A Deficiency Xerophthalmia¹
                                  in Children 6-71 Months of Age
                (Prevalence of any one or more indicates a public health problem)²


    INDICATOR                                                MINIMUM PREVALENCE
    Conjunctival xerosis/with Bitot‟s spot                                      > 0.50%
    (X1B)
    Corneal xerosis/ulceration/keratomalacia                                    > 0.01%
    (X2, X3A, X3B)
    Corneal scars³ (XS)                                                         > 0.05%

¹     Night blindness (XN) is a symptom included in the classification of xerophthalmia together with the
      other clinical eye signs. The consultation reaffirmed that a prevalence of night blindness >1% in
      children 24-71 months of age indicates a public health problem. In addition, a serum level of vitamin
      A (retinol) has been used with the clinical classification to provide supportive evidence of an important
      problem. A prevalence of >5% of serum levels < 0.35 umol/l is strong corroborative evidence of any
      clinical criteria met to identify an urgent public health problem.

²     The consultation did not review prevalence rates for xerophthalmia that indicate a public health
      problem. In view of recent findings from mortality and morbidity trials, any xerophthalmia in a
      population is worthy of careful review with potential for public health importance.

³     Lack of a history of traumatic eye injury or use of topical traditional medicines increase the specificity
      of this VAD indicator.




(Taken from “Indicators for assesing vitamin A deficiency and their application in
monitoring and evaluating intervention programmes”, p.5. WHO and UNICEF.
May 1994.)




EXCERPT FROM THE MICAH GUIDE                                  Page 57                              APPENDIX A
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                       Standards for Vitamin A Deficiency
 Biological Indicators of Subclinical vitamin A Deficiency in Children 6-71 Months of Age


     Prevalence Below Cut-Offs to Define a Public Health Problem and Its
                           Level of Importance
 Indicator (Cut-Off)              Mild                  Moderate                  Severe
 Functional
 Night Blindness
 (Present at 24-71              >0 - <1%               1% - 5%                    5%
 Mo.)

 Biochemical

 Serum retinol                2% - <10%              10% - <20%                  20%
 (0.70 umol/l)

 Breast milk retinol              <10%                10% - <25%                  25%
 (1.05 umol/l)

 RDR (20%)                       <20%                20% - <30%                  30%

 MRDR                             <20%                20% - <30%                  30%
 (Ratio 0.06)

 +S30DR (20%)                    <20%                20% - <30%                  30%

 Histological

 CIC/ICT                          <20%                20% - <40%                  40%


The level of public health importance is indicated by the prevalence noted in the above table.


(Taken from “Indicators for assesing vitamin A deficiency and their application in
monitoring and evaluating intervention programmes”, p.6. WHO and UNICEF. May 1994.)



EXCERPT FROM THE MICAH GUIDE                         Page 58                          APPENDIX A
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When does a public health problem exist?

A public health problem exists when either:

1) The prevalence in a population of at least two of the above biological indicators of Vitamin A
   status is below the cut-off.

Or

2) One biological indicator of deficiency is supported by at least four (two of which are
   nutrition and diet-related) of a composite of demographic and ecological risk factors such as:

        IMR > 75/1000 births; under-5 year MR > 100/1000 live births;
        full immunization coverage in < 50% of infants;
        <50% prevalence of breast-feeding in 6-month old infants;
        median dietary intake <50% recommended safe level of intake among 75% of children 1-
         6 years of age;
        two-week period prevalence of diarrhoea 20%;
        measles case fatality (MCF) rate >1%;
        no formal schooling for 50% of women 15-44 years of age;
        <50% of households with a safe water source.




EXCERPT FROM THE MICAH GUIDE                         Page 59                         APPENDIX A
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                     Standards for Iodine Deficiency
   Summary of IDD Prevalence Indicators and Criteria for a Significant Public Health
                                     Problem³

                                     Severity of Public Health Problem
                                       (Prevalence)

 Indicator         Target                  Mild             Moderate          Severe
                   Population
 Goitre grade >0   School-aged          5.0-19.9%           20.0-29.9%        >30.0%
                   children
 Median urinary    School-aged            50-59               20-49             <20
 iodine level      children
 (ug/l)
 TSH > 5mU/l       neonates             3.0-19.9%           20.0-39.9%        >40.0%
 whole blood
 Median Tg         Children and          10.0-19.9          29.9-39.9          >40.0
 (ng/ml serum)     adults


(Taken from “Indicators for assessing Iodine Deficiency Disorders and their control through
salt iodization”, p. 28. WHO and UNICEF. June 1994.)




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                         Standards for Iron Deficiency

 Proposed Classification of Public Health Significance of Anaemia in Populations Based on
                                  Prevalence of Anaemia

   Category of Public Health Significance                      Prevalence of Anaemia
                      High                                              >40
                    Medium                                           15.0-39.9
                      Low                                             5.0-14.9

¹ Total prevalence of anaemia where Haemoglobin levels below which anaemia is present
  follows: children 6 mo to 5 years 110 g/l; children 5-11 years 115 g/l; children 12-14 years
  120g/l; non-pregnant women 120 g/l; pregnant women 110 g/l; and men 130 g/l.

(Taken from “Indicators and Strategies for Iron Deficiency and Anaemia Programmes,
p. 13. WHO and UNICEF. August 1995.)




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           Appendix A-5

     Tables for Indicator
          Calculation




EXCERPT FROM THE MICAH GUIDE   Page 62   APPENDIX A
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                      DEFINITIONS OF THE INDICATORS

          Indicator                       Numerator                      Denominator


      Bitot's spots            Number of 6-59 mo olds with          Total number of 6-59
                               Bitot's spots                        month olds surveyed
      Night blindness          Number of 24-59 mo olds with         Total number of 6-59 mo
                               night blindness                      olds surveyed
      Breast milk retinol      Number of lactating mothers with     Total number of lactating
                               breast milk retinol < 1.05 mol/l.   mothers surveyed

      Adequate vitamin A       Number of  2 receiving              Total number of  2
      -Supplementation         supplement with correct timing of    surveyed;
                               last dose
                                              OR
                               Proportion of mothers receiving      Total number of mothers
                               supplement within prescribed time    surveyed.
                               period
      Vitamin A Programme      Number of households with a          Total number of
      Coverage                 vitamin A fortified food product     households surveyed
      -Fortification           AND which is given to children/
                               mothers
      Vitamin A Programme      Number of children who eat the       Total number of children
      Reach                    vitamin A target foods within        surveyed
      -Dietary                 previous week

    Diversification
     (i.e., mothers who
     have heard programme
     message and put it into
     practice)




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         Indicator                          Numerator                       Denominator


      Goitre coverage           Number of school-aged children         Total number of school-
                                (6-12 yrs) with goitre                 aged children (6-12 yrs.)
                                                                       surveyed
                                                OR

                                Number of pregnant mothers with        Total number of pregnant
                                goitre                                 mothers surveyed

                                                OR
                                Number of women aged 6 to 30           Total number of women
                                yrs. old with goitre                   aged 6 to 30 yrs. old
                                                                       surveyed
      Urinary iodine level      Number of school-aged children         Total number of school-
                                (6-12 yrs) with urinary iodine         aged children (6-12 yrs)
                                levels < 20 g/l                       surveyed

      Iodized oil capsule             coverage
                                Number of women of child-              Total number of women
                                bearing age receiving iodized oil      of child-bearing age
                                capsule                                surveyed
      Salt iodization           Number of households with salt         Total number of
                                testing positive for iodine/iodate     households tested
      Iron Programme            Number of women of child-              Total number of women
      Haemoglobin levels        bearing age with Hg levels < 120       of child-bearing age
                                g/l (non-pregnant) and < 110 g/l       (pregnant/non-pregnant)
                                (pregnant)                             surveyed
      Iron Programme            Number of children 6-59 months         Total number of children
      Haemoglobin levels        with Hg levels < 110 g/l               6-59 months surveyed
      Iron Programme            Number of women of child-              Total number of women
     -Supplementation           bearing age who received iron          of child-bearing age
                                capsules during the prescribed         surveyed
                                time
      Iron Programme            Number of households with an           Total number of
      -Fortification            iron fortified food product given to   households surveyed
                                mothers/children
      Iron Programme            Number of women with                   Total number of women
     -Dietary diversification   inadequate dietary iron intake         surveyed


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         Indicator                    Numerator                    Denominator


      Iron Programme       Number of mothers who have         Total number of mothers
     -Education            heard the programme message        surveyed
                           AND give “correct” response to
                           foods that message promotes
                           (knowledge)
      Diarrhoeal Disease        coverage
                           Number of children < 60 months     Total number of children
                           with diarrhea                      < 60 months surveyed
      Sanitation           Number of householdsin defined     Total number of
                           “safe and adequate” category       households considered in
                                                              survey
      Water Supply         Number of household residents in   Total number of
                           defined “safe and convenient”      household residents
                           categories                         surveyed
      Malaria coverage     Number of children under 5 with    Total number of children
                           malaria                            under 5 surveyed
      Hookworm coverage    Number of children under 5 with    Total number of children
                           hookworm                           under 5 surveyed
      Schistosomiasis      Number of children under 5 with    Total number of children
      coverage             schistosomiasis                    under 5 surveyed
      DPT3 coverage        Number of 12-23 mo olds            Total number of 12-23
                           receiving DPT3 before first        month olds surveyed
                           birthday
      Measles coverage     Number of 12-23 mo olds            Total number of 12-23
                           receiving measles before first     month olds surveyed
                           birthday
      OPV3 coverage        Number of 12-23 mo olds            Total number of 12-23
                           receiving OPV3 before first        month olds surveyed
                           birthday
      BCG coverage         Number of 12-23 mo olds            Total number of 12-23
                           receiving BCG before first         month olds surveyed
                           birthday
      Timely               Number of 6-9 month olds           Total number of 6-9
      complementary        receiving breast milk and          month olds surveyed
      feeding              complementary foods


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         Indicator                     Numerator                     Denominator

      Continued             Number infants 20-23 months still   Total number of 20-23
      breastfeeding at      breastfeeding                       months olds surveyed
      2 years
      Adequate              Number of infants 6-24 months       Total number of 6-24
      complementary foods   receiving 3+ meals of               month olds surveyed
      daily intake          complementary foods/day
      Nutritional Status:   Number of under-fives who fall Total number of under-
      Weight-for-age        below -2 SD from the median    fives weighed
                            weight-for-age of the NCHS/WHO
                            standard;
                            Number who fall below -3 SD
      Nutritional Status:   Number of under-fives who fall      Total number of under-
      Height-for-age        below -2 SD from the median         fives measured
                            height-for-age of the NCHS/WHO
                            standard;
                            Number who fall below -3 SD
      Nutritional Status:   Number of under-fives who fall      Total number of under-
      Weight-for-height     below -2 SD from the median         fives weighed and
                            weight-for-height of the            measured
                            NCHS/WHO standard;
                            Number who fall below -3 SD




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